Medicine and the arts. The doctor by Luke Fildes. Commentary

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

ISSUE

The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore.

EVIDENCE

There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence.

IMPLICATIONS

We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.